Form Approved

SOCIAL SECURITY ADMINISTRATION OMB No. 0960-0059

WORK ACTIVITY REPORT — EMPLOYEE

IDENTIFICATION - TO BE COMPLETED BY SSA
Name of Claimant or Beneficiary Claimant or Beneficiary's SSN

Blind Not Blind

- -
Name of Wage Earner (if different from Claimant or Beneficiary) Wage Earner's SSN

- -
Claimant or Beneficiary is Receiving:

Social Security Disability Insurance (SSDI) Benefits Both SSDI and SSI Disability Benefits

Supplemental Security Income (SSI) Disability Benefits Neither SSDI or SSI Disability Benefits
PART I - TO BE COMPLETED BY SSA
Date
1 . Please use this form to tell us about your work since

2. We need to know this information because:

ANSWER THE QUESTIONS ON THIS FORM AND RETURN IT AND ANY OTHER INFORMATION ABOUT YOUR CLAIM
TO THE SOCIAL SECURITY OFFICE THAT GAVE (OR SENT) YOU THE FORM.

PART II - TO BE COMPLETED BY PERSONS APPLYING FOR OR RECEIVING BENEFITS

You should answer each of the questions below as best and with as many details as you can. This information will help us decide if you
should get or keep getting benefits. For any question below, if you need more space, use item 9, on pages 5 and 6. Remember to write the
number of the question that you are answering in item 9.

1 . HAVE YOU WORKED SINCE THE DATE SHOWN IN ITEM 1 OF PART 1, ABOVE?

YES If you did work, go to item 3 and answer the rest of the questions and sign and date the form.

NO If you did not work, but earnings were reported for you as shown in item 2 of Part I above, go to item 2 below.

2. REPORTED WORK OR EARNINGS

If you did not work, but earnings were reported for you as shown in Item 2 of Part 1, explain what the pay was for.

For example, sometimes pay is sick pay, vacation pay or holiday pay that you earned, or for work that you did before becoming unable
to work because of your condition.

If you can't explain the earnings reported for you or you don't remember what the total earnings are for, ask your employer(s). If your
employer(s) cannot help you, ask your local Social Security Office to help you.

Explanation of Earnings:

If you need more space, use Item 9. Then go to Items 8 and 10.
Form SSA-821-BK (09-2009) ef (09-2009) Formerly SSA-821-F4 & SSA-3945-BK 1 Destroy Prior Editions
3.
TELL US ABOUT YOUR WORK SINCE THE DATE IN ITEM 1 OF PART 1 ABOVE.
(If you are not sure about some things, ask your employer to help you. If you need more space, use Item 9, on pages 5 and 6.
Remember to write the number of the question that you are answering in Item 9.)

A. Employer's Name Employer's Address (Include street, city, state, & ZIP)

Date Work Started Date Work Ended Starting Hourly Pay Current or Ending Pay

Job Title Number of Hours (on average) Supervisor's Name Supervisor's Telephone
Worked Number (Include area code)

Per Day Per Week

Check each block below that is true for this work:

I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
type of work I was doing (e.g., You were a plumber and changed to lighter work.) because:

of my medical condition.

special conditions at work related to my medical condition that allowed me to work were removed.

I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

B. Prior Employer's Name Employer's Address (Include street, city, state, & ZIP)

Date Work Started Date Work Ended Starting Hourly Pay Current or Ending Pay

Job Title Number of Hours (on average) Supervisor's Name Supervisor's Telephone
Worked Number (Include area code)

Per Day Per Week

Check each block below that is true for this work:

I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
type of work I was doing (e.g., You were a plumber and changed to lighter work.) because:

of my medical condition.

special conditions at work related to my medical condition that allowed me to work were removed.

I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

Form SSA-821-BK (09-2009) ef (09-2009) 2

C. Prior Employer's Name Employer's Address (Include street, city, state, & ZIP)

Date Work Started Date Work Ended Starting Hourly Pay Current or Ending Pay

Job Title Number of Hours (on average) Supervisor's Name Supervisor's Telephone
Worked Number (Include area code)

Per Day Per Week

Check each block below that is true for this work:

I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
type of work I was doing (e.g., You were a plumber and changed to lighter work.) because:

of my medical condition.

special conditions at work related to my medical condition that allowed me to work were removed.

I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

4. Since the date you started working on or after the date shown in Item 1 of Part 1, above, have there been any months during which
you earned over $200 per month through 12/2000 or over $530 beginning 01/2001(before anything was withheld; e.g., taxes)?

No (Go to Item 5.)

Yes (Tell us which month and year and the amount you earned that month in the chart below. If you need more
space, use Item 9, on pages 5 and 6. Remember to write the number of the question that you are answering in Item 9.)

MONTH/YEAR AMOUNT MONTH/YEAR AMOUNT MONTH/YEAR AMOUNT

$ $ $

$ $ $

$ $ $

$ $ $

5. SPECIAL WORK CONDITIONS - Do (Did) you get special help on-the-job or extra pay in any of the jobs that you told us about
in Item 3?
No (Go to Item 6.)

Yes Check all of the boxes that are true for you and tell us for which job(s) you received that help and tell us
about any other special condition(s) or help that you got on a job.

I needed and got special help from other I was given a job based on my past services to an
workers in doing my job. employer.

I was given special equipment or was given
work that was suited to my condition.
I was allowed to work at a lower standard of
productivity.
I worked for a relative or friend.
I worked irregular hours or took frequent rest periods.
I worked in a sheltered work center.
I was hired through a special program for training or
therapy (e.g., vocational rehabilitation, supported
employment).

Form SSA-821-BK (09-2009) ef (09-2009) 3

5. SPECIAL WORK CONDITIONS - Continued

Check all of the boxes that are true for you and tell us for which job(s) you received that help and tell us about any other special
condition(s) or help that you got on a job.

My job duties were different than other workers’ job duties doing the same work because:

I worked fewer hours. I got different pay.

I had different duties; fewer or easier duties. I had extra help, extra supervision, or a job coach.

I was given special transportation to and from work. I got special help getting ready for work.

I was paid for extra rest periods at work or extra time off from work and other workers were not.

Other special help. (Explain below.)

In the space below, tell us for which job(s) you received the special help. If you need more space, use Item 9.

6. OTHER/SPECIAL PAYMENTS - Do (Did) you get any payment(s) from an employer in addition to regular pay? For example, did you
get any tips, bonuses, sick or disability pay, vacation pay, meals, room or rent, transportation or use of a car or vehicle, or childcare?

No Go to Item 7.

Yes Tell us below what these payments were. If you need more space, use Item 9.

AMOUNT OR ESTIMATE
EMPLOYER TYPE OF PAYMENT MONTH & YEAR
OF THE DOLLAR VALUE

7. SPECIAL WORK EXPENSES (IMPAIRMENT-RELATED WORK EXPENSES) - Do (Did) you spend any money of your own earnings
for any things or services related to your condition that allowed you to work and for which you did not get paid back?

For example, medicines, bandages, braces, wheelchair, artificial arm or leg, braille equipment, special telephone or computer
equipment, modifications to home (wider doorways, roll-in shower, ramps, wheelchair-lift), or modifications to a car (automatic
wheelchair-lift), personal assistance (personal care attendant).

No Go to Item 8.

Yes Tell us below about the bills, or part of the bills, that you paid for things or services related to your medical
condition that you needed in order to work. (Upon review, you may be required to provide proof of these
expenses.) Do not show any bills or amounts paid by an insurance company or any other organization or
person or paid back to you by an insurance company or other organization or person. (Example: An
insurance company might pay all or part of the bill at a later time.)

Form SSA-821-BK (09-2009) ef (09-2009) 4

7. SPECIAL WORK EXPENSES (IMPAIRMENT-RELATED WORK EXPENSES) - Continued

ITEM OR SERVICE COST DATE(S) PAID (MONTH & YEAR)

SPECIAL TRANSPORTATION COST

MODIFIED VEHICLE $

TAXI-TYPE SERVICE $

8. VOCATIONAL REHABILITATION - Are (Were) you getting any help from a vocational rehabilitation or employment services provider
to get the services and/or training you need to get ready to start working, find work or keep working?

No If you answered no, would you like to get these services? Yes No Go to Item 10.

Yes Tell us the name and address of the people who are (were) giving you vocational rehabilitation or employment
services and training.

Vocational Rehabilitation/Employment Services Provider

Name Address (Include street, city, state & ZIP)

Counselor's Name Counselor's Telephone Number (Include area code)

If you need more space, go to Item 9, below.

9. More Space. For any question above, if you need more space, use space below. Remember to write the number of the question that
you are answering before you begin.

Form SSA-821-BK (09-2009) ef (09-2009) 5

9. More Space - Continued. For any question above, if you need more space, use space below. Remember to write the number of the
question that you are answering before you begin.

10. I authorize any employer, agency or other organization to disclose to the Social Security Administration or the State agency that may
determine or review my entitlement to disability benefits any information about my medical condition or my work.
SIGN AND DATE THIS FORM
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.
Signature of Claimant, Beneficiary, or Representative Date Telephone Number (Include area code &
e-mail address)

Mailing Address (Number and Street)

City and State ZIP Code County

-
Witnesses must sign ONLY if this statement is signed by mark (e.g., X) above. If signed by mark (X), two witnesses to the signing who
know the person making the statement must sign below, giving their full addresses and telephone numbers.
1. Signature of Witness 2. Signature of Witness

Address (Number and street, city, state, and ZIP code) Address (Number and street, city, state, and ZIP code)

Telephone Number (Include area code) Telephone Number (Include area code)

Form SSA-821-BK (09-2009) ef (09-2009) 6

 PRIVACY ACT/PAPERWORK REDUCTION ACT STATEMENT

Sections 205(a), 223(d), 1612, 1613 and 1633(a) of the Social Security Act, as amended, authorize us to collect this
information. The information is needed to make a determination on your claim. The information you furnish on
this form is voluntary. However, failure to provide all or part of the information could prevent an accurate and
timely decision on your benefit eligibility.

We rarely use the information you supply for any purpose other than for making a determination on your disability
claim. However, we may use it for the administration and integrity of Social Security programs. We may also
disclose information to another person or to another agency in accordance with approved routine uses, which
include but are not limited to: (1) to enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage; (2) to comply with Federal laws requiring the release of
information from Social Security records (e.g., to the Government Accountability Office and Department of
Veteran Affairs); (3) to make determinations for eligibility in similar health and income maintenance programs at
the Federal, State, and local level; (4) to State agencies or other agencies providing services to disabled children;
(5) to contractors for the purpose of assisting SSA in the administration of the Ticket to Work and Self Sufficiency
Program; and (6) to facilitate statistical research, audit or investigative activities necessary to assure the integrity of
Social Security programs.

We may also use the information you provide in computer matching programs. Matching programs compare our
records with records kept by other Federal, state or local government agencies. Information from these matching
programs can be used to establish or verify a person's eligibility for Federally funded and administered benefit
programs and for repayment of payments or delinquent debts under these programs.

A complete list of routine uses for this information is available in System of Records Notice 60-0050, 60-0089,
60-0295, 60-0320. The notices, additional information regarding this form, and information regarding our
programs and systems, are available on-line at www.ssa.gov or at your local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507,
as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it will take about
45 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. To find the nearest office, call
1-800-772-1213 TTY# (TTY 1-800-325-0778). Send only comments on our time estimate above to: SSA, 6401
Security Blvd., Baltimore, MD 21235-6401.

Form SSA-821-BK (09-2009) ef (09-2009) 7

 FOR SSA USE ONLY - DO NOT WRITE ON THIS PAGE

11. A. Contact made:

In Person By Mail By Telephone Other

B. Completed by:

Claimant SSA Representative Other

If "Other," show:
Name Address Telephone Number

Relationship

12. Interviewer/Reviewer Checklist. SSA interviewers and reviewers should check all items that apply and discuss all "YES" or "NO"
answers below, except for reminder items or when a final determination is prepared.

A. Work within waiting period or within 12 months of onset (SGA denial or reopening/revision YES NO
to denial applies)

B. MIE diary involved - DDS referral needed YES NO

C. Title II TWP determination YES NO

D. Special considerations, situations, assistance (Subsidy - specific or nonspecific) YES NO

E. IRWE YES NO

F. SGA (after applicable subsidy/IRWE deduction(s)) YES NO

G. UWA (initial claim - DDS jurisdiction. FO has documented significant break in work and made YES NO
UWA recommendation to DDS for a final determination)

H. UWA (Continuing disability review - FO jurisdiction) YES NO

I. EPE impairment severity issue - DDS referral needed (reminder item) YES NO

J. EPE reinstatement/suspension/termination YES NO

K. Due process required YES NO

L. Concurrent Title II & Title XVI Income & Resources or 1619 action needed YES NO

M. Other issue(s)/comment(s) not noted above YES NO

Discussion:

13. Signature and title of SSA interviewer/reviewer 14. FO/PSC code 15. Telephone Number 16. Date

Form SSA-821-BK (09-2009) ef (09-2009) 8